Medication Errors
&
Risk Reduction
How do you define a medication
error?
“any preventable event that may cause or
lead to inappropriate medication use or
client harm while the medication is in the
control of the healthcare professional,
client, or consumer.”
Definition from the National Coordinating Council for Medication
Error Reporting and Prevention (NCC MERP)
Why are medication errors such
a concern?
• Because a shocking number of patients die every
year in United States hospitals as a result of
medication errors, and many more are harmed.
• Medication errors are the fourth to sixth leading
cause of death in America.
• Medication errors are the most common cause of
morbidity and preventable death in hospitals
today.
What are key factors contributing to
medication errors by the health care
provider?
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Many new drugs on the market
Distractions/Interruptions
Understaffed facilities/overworked nurses
Wrong med, dose, patient, route, time.
Omission of dose
Discontinued meds at D/C misinterpreted
Misinterpretation
Miscalculations
Lack of clinical evaluation/assessment
Who are the collaborative partners in
medication administration
• Prescribers
• Pharmacists
• Transcribers/Clerical Staff
• Nurses
• Patient / Personal Caregivers
Types of Medication Errors
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Prescribing error
Omission error
Wrong time order
Unauthorized drug error
Improper dose error
Wrong dosage-form error
Wrong drug preparation error
Wrong administration technique error
Deteriorated drug error
Monitoring error
Compliance error
Other errors not classified above
Common Causes of Medication
Errors
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Ambiguous strength designation on labels
Drug product nomenclature ( look/sound alike)
Equipment Failure
Illegible handwriting
Improper transcription
Inaccurate dosage calculations
Inadequately trained personnel
Inappropriate abbreviations used in prescribing
Labeling errors
Excessive workload
Medication unavailable
Reduction of Medication ErrorsPlanning
Use only approved abbreviations
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• Question unclear orders
• Do not accept verbal orders unless emergency (repeat back for
clarification)
• Follow agency policy and procedures
• Ask for client participation & provide medication education
• Be familiar with the medication ordering system and delivery devices
• Always review patients medications with respect to desired outcome
• Verify all drug orders prior to initial dose administration.
• Provide medications on time
• When standard dosage charts are not available have a second nurse
check the drug calculations
• If a large dose is ordered; more than 2 tablets, ampules or vials this
should raise a flag! Consult with Pharmacy!
• Listen to the patient; hold if they have concerns and double check the
order
• NEVER!!!! Give any medication prepared by another nurse (You should
prepare all medications that you administer this is the only way to be
100% sure of what medication you are administering).
Reduction of Medication ErrorsImplementation
 Assess
◦ Food or medication allergies
◦ Current health concerns
◦ Use of OTCs and herbal supplements
◦ Adverse reactions
 Review
◦ Recent laboratory tests
◦ Recent physical assessment findings
 Identify
◦ Need for education about medication regimen
Reduction of Medication ErrorsImplementation
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Be aware of potential distractions
Remove distractions if possible
Focus on medication administration task
Practice six rights
Maintain knowledge of medications and
dosage calculations
• Always have another nurse re-check your
drug calculations
Reducing Medication Errors in
Health Care Facilities
• Methods:
• Automated, computerized, locked
cabinets for medication storage on
client-care units
• Risk management departments
• Collaboration with nursing to modify
policies and procedures
Reporting and Documenting
Medication Errors
• Document and Report according to agency policy.
• Report the medication error with an incident report.
• In relation to the associated legality, why is
documentation of the error important?
• Quality Improvements
Addressed in the 2011 National Patient Safety Goals
Address NPSG.01.01.01& 03.04.01,03.05.01, 03.06.01
Agencies that Collect and Report
on Medication Errors
• FDA’s MedWatch
• Institute of Safe Medication Practices (ISMP)
• MedMarx
Nurse Practice Act and
Standards of Care
• The Nurse Practice Act serves as a minimal guideline to
determine what a nurse should or should not perform to
ensure safe and competent care.
• A medication error may be considered negligence and
involve an investigation from the NC Board of Nursing
and possibly result in a revoked licensed to practice as a
Registered Nurse.
• How will you ensure that you will administer medication
safely?